醫院中央氣體系統管理運用失效模式與效應分析對病人安全之探討-以某醫學中心為例

Using the Failure Mode and Effects Analysis to Evaluate the Impact of Hospital Central Gas System on Patient Safety - The Case of a Medical Center

張文弘(Wen-Hung Chang)

指導教授 ： 郭乃文

共同指導教授 ： 黃崇謙(Chung-Chien Huang)

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2011年)

https://doi.org/10.6831/TMU.2011.00110

摘要

近年來台灣各醫學中心發生不少系統管理上之重大公安事件，突顯了醫院內各系統管理安全性的問題。因此，隨著病人安全課題日益受到重視，特別是中央氣體系統，對病人治療扮演著生命維持重要角色。故本研究運用失效模式與效應分析結果應用於某教學醫院中央氣體系統管理層面，期讓管理者能夠即早探討出潛在危險因子，建立矯正預防措施，確保系統正常運作及維護病人安全。
本研究方法為運用失效模式與效應分析(FMEA)於某教學醫院中央氣體系統管理對病人安全作探討，再依團隊腦力激盪列出風險優先數值，確認潛在危害問題點後，採取必要的矯正措施與預防對策，再結合與實際工作者訪談及系統異常回顧資料統計分析，呈現分析改善與回顧檢討相對照之研究結果。
研究結果指出中央氣體系統管理層面潛在危險因子主要有三類，第一類為環境之電力配置，第二類為建築師無規劃經驗、警報之即時性傳遞及系統備援等問題，第三類為斷氣時病患處置及驗收測試完整性，研究除探討潛在危險因子外並以實證改善如：增訂規範要求、自主檢查項目、自動化技術方式、內建失效安全等機制。在個案訪談及回顧資料分析結果，瞭解液氧槽管理不當及管路錯接為病人安全之主要癥結，發現系統最常發生問題為空壓機系統之異常。
整體而言，本研究運用FMEA的方法，除探討整個系統管理層面潛在危險因子並改善外，以實證將原教學醫院中央氣體系統管理模式提升。再利用個案訪談及回顧資料分析與FMEA研究結果相對照，相信本研究結果除達成品質管理要求，也增進醫院病人安全；故本研究將FMEA實際應用於該系統管理經驗，將可提供其他醫療院所氣體系統管理者参考借鏡。

關鍵字

失效模式與效應分析 ； 中央氣體系統 ； 風險優先數值 ； 病人安全

並列摘要

Background and purpose: In recent years, many medical centers in Taiwan experienced
significant near miss safety events, raising public concern about the hospital system management
assurance issues. Thus, to voice on promoting patient safety, the central gas system applied to
the patients treating plays an important role to support life. This study attempts to analyze the
failure modes and effects which can immediate apply to the system management, and can explore the potential risk factors to establish corrective measures for managers to operate system
normally and enhance patient safety.
Methods: This study applied Failure Mode and Effects Analysis (FMEA) to manage patient
safety on the central gas system in a teaching hospital then proceeded with team brainstorming, listing out prioritized risk factors, and identified fault modes.It then used root cause analysis to implement the necessary corrective actions to prevent the potential risk factors and interviews
the related workers finding out abnormal data of the system for statics and analysis.
Results and Conclusion: The study concluded with some of the potential management risk
factors, sorting these factors to three categories, as follows: the first category is the central gas system electrical power supply, the second categories are : lack of experience for architects, no real time alerts, lack of back up system, and the third categories are lack of central gas supply when the patient treatment, and the acceptance test of the integrity. This study identified risk prioritized factors and achieved improvement as follows: standard operating specifications, independent inspection program, automation mode, built-in fail-safe mechanisms to enhance patient safety. After study subjects with in depth interviews and data analysis in study, it shows liquid oxygen tank’s inappropriate mainteance situation, crossed pipeline connection problems, and severely jeopardize patient safety. The most abnomal problem is the air compressor system
function.
In short, This FMEA study applies to upgrade system management, identify prioritized risk
factors and improve to enhance the central gas system safety of the case teaching hospital. We believe this study result provides not only fulfilling the quality management requirements, but also promoting patient safety. In this study, the FMEA method was actually applied to the system management and has verified that the result is effective, so that the experience can be
applied to the central gas system management of other health care institutions.

並列關鍵字

Failure Mode and Effects Analysis ； Central gas system ； Patient Safety

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